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PALLIATIVE OR HOSPICE CARE – Focus on support and care of the dying person and FAMILY, with the goal of FACILITATING a PEACEFUL and DIGNIFIED DEATH. Improved QUALITY of LIFE rather than CURE – controlling the patient’s SYMPTOMS and ensures his/her WELL-BEING until his death.


Control and RELIEVE PAIN and symptoms of illness.

Offer support groups and emotional support for the patient, FAMILY and friends.

Provide SPIRITUAL support.

Establish and meet PHYSIOLOGIC needs – mouth care, grooming, sleep, nutritional and elimination.

END OF LIFE: “Possible cause of delirium/patient change in behavior in CANCER”

  • Uncontrolled pain.              

  • Medication reaction.            

  • Bladder distension.                    

  • Deterioration of respiratory condition.

  • Presence of cerebral metastases.

  • Anxiety about death.

  • Constipation/fecaloma.

  • Staging describes the extent or severity of a patient’s cancer. Knowing the stage of disease helps the doctor plan treatment and estimates the patient’s prognosis.

    TNM system:

    Tumor - size and/or extent (reach) of the primary tumor.

    Node - the amount of spread to nearby lymph nodes.

    Metastases - the presence of metastasis.

    Plus: Physical exams, imaging procedures, laboratory tests, pathology reports, and surgical reports provide information to determine the stage of a cancer.

    *Tumor grade is the description of a tumor based on how abnormal the tumor cells and tumor tissue look under a microscope.

    *Tumor grade is an indicator of how quickly the tumor is likely to grow and spread.

Mouth care: Brushing teeth/dentures and cleaning and moistening the lips. – When doing mouth care assessed: lips, tongue, saliva, teeth, mucous membranes, gums and breath.

Oral problems:         

  • Dry mouth – ice cube, hydration, and water spray. Alcohol free mouth wash and moisturizer.

  • Halitosis – mouthwash 25 mL + 25 mL water/NS. Baking soda in 1L of NS.

  • Bad taste – frozen fruit to suck.

  • Inflamed – soft-bristle toothbrush.

  • Mucus membrane fungal infection – anti-fungal as prescribed.

Morphine Myths:

  • Explain that morphine does not cause death but effectively relieve pain and afford greater dignity in patient last days.

  • Does not cause addiction – lowest dose is given – only for pain not to become addict.

Note: If terminal stage: the change of LOC by patient is not only cause by morphine neurotoxicity but also the progression of the illness of the patient.

Dehydration on a dying person:

  • Reduce bronchial secretions and the resultant congestion.

  • Decrease the possibility of developing edema.

  • Have an antalgic effect due to secretion of endorphins.

  • PREPARE patients through grief:

    Provide physiologic needs and safety.

    Role modeling by those successfully cope.

    Establish coping behavior that was successful in the past.

    Prepare support systems (explain to family).

    Allow to verbalize feelings.

    Refer to support groups.

    Expand coping behaviors by introducing new mechanism.


Clinical signs of IMPENDING, IMMINENT and CLINICAL death:


●Loss of muscle tone (bladder or bowel incontinence, decrease GI motility).●Slow circulation (mottling of skin, cool skin). ●V/S changes (weak pulse, hypotension, rapid shallow, irregular mouth breathing)

Sensory impairment (HEARING last).


●Fixed dilated pupils, Loss of reflexes, faster-weak pulse, Cheyne-stokes respiration, death rattle.


●Total lack of response to external stimuli.

●No reflexes.

●No muscular movement.

●Flat line.


  • Stomatitis/mucositis or esophagitis.

  • Nausea and vomiting.

  • Alopecia.

  • Skin.

  • Fatigue.

  • Anorexia.

  • Xerostomia.

  • Diarrhea.


●Use soft-bristle toothbrush. ●Do not eat spicy, hard, too cold/too hot food.

●Eat crackers. ●Avoid odorous foods. ●Drink ginger ale. ●Anti-emetic.

●Use wig. ●Cut hair before therapy. ●Do not use a lot of shampoo/brush lightly.

●Hydrate well. ●Use lotion. ●Protect from sun/trauma.

●Rest period between activities.

●Make food appetizing (offer favorite food). ●Small frequent feeding.

●Increase fluid intake. ●Water spray/ice cubes. ●Artificial saliva.

●Increase carbohydrates. ●Hydrate well. ●Anti-diarrheal.

INTERNAL RADIATION: Types:  sealed and unsealed

SEALED: Radium, iridium, and cesium. Source is placed in the cavity or adjacent to the cancer. Douche, enema, perineal prep, foley catheter before insertion of cervical radium.

FLAT position. ●NEVER HANDLE RADIUM DIRECTLY, use LONG-HANDLE FORCEPS. ●Do not allow patient to be exposed to PREGNANT women and CHILDREN. ●ISOLATE patient in a PRIVATE room.

UNSEALED: Radio-isotope, radionuclide – oral and intravenous.

●Radiation is excreted in the urine, sweat, vomitus and stool.

●Careful handling of gowns, dressing, utensils, and linens.

●Wear a detection badge to determine exposure.

EXTERNAL RADIATION: Daily/5 days a week – last 2-10 weeks depending on the type of cancer and the goal of treatment. Hyperfractionated radiation therapy.

Nursing care: Marks must not be removed during the entire treatment. Keep the skin dry-lotion and talcum powder are contraindicated.

Patient teaching: No eating 2-3h before treatment and 2h after – to prevent nausea.

Avoid exposure to sunlight, extreme temperature, tight constricting clothing, fatigue and crowded places. DOES NOT MAKE THE PATIENT RADIOACTIVE.

PRINCIPLES: Nursing care●Time: Not > 30 minutes per care provider per shift.

●Distance: As far as possible 6 feet away from the source.●Shield: Protective LEAD apron.

BREAST CANCER: Risk factors: Age, family history of breast cancer, early menarche and late menopause, previous cancer of the breast, uterus or ovaries, nulliparity, obesity, high dose exposure to radiation.


  • Mass felt during breast self examination (Usually at the upper outer quadrant, beneath nipple or axilla).

  • Nipple retraction or elevation.

  • Breast asymmetry (affected higher).

  • Bloody or clear discharge

  • Assessments:

  • Skin dimpling or ulceration.

  • Skin edema or peau d’orange skin.

  • Axillary lymphadenopathy or lymphedema.

  • Presence of lesion in mammography.

  • Note: Early detection is important (Monthly BSE)

Nonsurgical interventions:

  • Chemotherapy.

  • Radiation therapy.

  • Hormonal manipulation via the use of medication in postmenopausal women or other medications such as tamoxifen (Novadex) for estrogen receptor – positive tumors.

Surgical interventions:

  • Lumpectomy – tumor is excised and removed.

  • Simple mastectomy – Breast tissue and nipple are removed. Lymph nodes are left intact.

  • Modified radical mastectomy – Breast tissue, nipple, and lymph nodes are removed. Muscles are intact.

Post-operative interventions:

  • Monitor vital signs.

  • Position patient in semi-Fowler’s position; turn from the back to the unaffected side, with the affected arm elevated above the level of the heart to promote drainage and prevent lymphedema.

  •  Encourage coughing and deep breathing.

  • If drain is in place, maintain suction and record (COCA). Monitor for infection or swelling.

  • Place a sign above the bed stating: No IV’s, No injection, No BP, and No Venipuncture in affected arm.

Patient restrictions following mastectomy:

  • Keep affected arm elevated (avoid hanging dependent).

  • Do not overuse the affected arm (no heavy lifting).

  • Avoid trauma, cut, bruises, burns.

  • Avoid wearing constrictive clothing or jewelry.

  • Wear gloves when gardening.

  • Use thick oven mitten when cooking.

  • Call physician if sign of inflammation occur.

  • Avoid strong sunlight exposure.

  • Wear medical alert bracelet.

  • Encourage support group.

CANCER WARNING SIGNS: CAUTION US: C- hange in bowel or bladder habit. A- sore that does not heal. U- nexplained anemia. T- hickening lump in breast or elsewhere. I- ndigestion or difficulty in swallowing.  O- bvious change in warts or moles. N- agging cough or hoarseness of voice. U- nusual bleeding or discharge. S- udden weight loss.



●Skin care.

●Range of motion exercises.



●Hygiene measure.


Can perform the tasks of orderly and certain INVASIVE task:

●Dressing change. ●Suctioning.

●Urinary catheterization.

●Medication administration (oral, subcutaneous, and intramuscular)


Can perform the task of LPN:

●Responsible for assessments.

●Planning of care.

●Initiating teaching.

●Administering medication intravenously.


  • Apply invasive measures for the maintenance of therapeutic equipment. (Tubes, stomies, catheter, and drains).

  • Take specimens, according to prescription. (Except blood).

  • Provide care and treatment for wound and alterations of the skin and teguments, according to a prescription or a nursing plan.

  • Observe the state of consciousness of a person and monitor neurological signs.

  • Mix substances to complete the preparation of a medication, according to prescription. (Insulin and vaccines).

  • Administer prescribed medications and other prescribed substances via routes other than the intravenous route.

  • Participate in vaccination operations under the public health act.

  • Introduce an instrument or a finger, according to a prescription, beyond the nasal vestibule, labia majora, urinary meatus, or anal margin or into an artificial opening in the human body.

  • Introduce an instrument, according to a prescription, into a peripheral vein in order to take a specimen (certification needed).

  • Do NOT delegate what you can EAT: E-valuation A-ssessment T-eachings

BLOOD TRANSFUSION: Restore blood volume, ↑ mass of circulating RBC, ↑ O2 carrying capacity of blood. Blood test within hours before transfusion to assess effectiveness of the treatment.

Autologous transfusion: Patient receives his own blood.

Allogeneic transfusion: Involves donor and recipient.

Sign and symptoms of moderate anemia:

●Palpitations. ●Pallor. ●Weakness. ●Diaphoresis. ●Dyspnea.


  • Allergic: Antibody-antigen reaction, sensitivity to plasma proteins. Flushing, itching, urticaria, bronchial wheezing, dyspnea, chest pain and cardiac arrest.

  • Hemolytic: Incompatibility to with patient’s blood. Chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, and hypotension.

  • Febrile: Patient’s blood is sensitive to WBC, platelets and plasma protein. Fever, chills, warm, flushed skin, headache, anxiety and muscle pain.

  • Circulatory overload: Blood is administered faster than the circulation can accommodate. Coughing, dyspnea, crackle, distended neck veins, tachycardia and hypertension.

  • Septic: Blood administered is contaminated. High fever, chills, vomiting, diarrhea, and hypotension.

  • Common transfusion reactions “CRAMPS”:

    C-hills and diaphoresis. R-ash (itchiness). A-nxiety.  M-uscle pain, back pain, chest pain, and headache. P-allor and cyanosis. S-OB, S-welling

Verification of the material:  CONSENT!

When the blood product arrived. Immediately two nurses INDEPENDENTLY check the blood product by comparing it to the medical prescription with the information on the issue slip and blood product label:

  • The patient identity (surname, first name, and file number).

  • Blood group and Rh factor (indicated on the blood unit).

  • The name of the product and the donation #.

  • Appearance of the blood product.

  • Expiratory date and time.

Integrity of the bag: intact and dry packaging, intact ports or caps.


  • STOP the transfusion immediately!

  • Keep a venous access open with 0.9% NaCl KVO.

  • Assess vital signs.

  • Notify MD:  call code if patient is suffering cardiopulmonary arrest.

  • Verify the order – check to ensure that the patient name and registration number on the blood bag label is exactly the same with the patient’s identification.

  • Save the unit of blood and send to blood bank.

  • Notify the blood bank that transfusion reaction has occurred.

  • Complete a transfusion reaction form.


  • Right product:

-unit of blood as prescribed (Plasma, packed RBC, cryoprecipitate, or platelets.)

-Right blood group, Rh factor, integrity/appearance.

-All matches the prescription, label and issue slip.

  • Right patient:

-surname, first name, and file/LOT number.

-Correct identification given by the patient and bracelet + allergy.

  • Right route:

-patency of the route (REEDA-infiltration), IV catheter gauge

18-massive hemorrhage, major surgery

20-adult BT, pre-op patient, labor

22-Routine IV therapy in adult, permissible for adult BT

24-Routine IV therapy and BT for neonates and geriatrics.

  • Right dose:

-One blood unit or more?

  • Right time: 1-4 hours (not less not more).

Note: 5% dextrose in water will haemolyse red cells. Intravenous solutions containing calcium, such as Lactated Ringer's solution, can cause clots to form in blood. ●Initial flow rate 1mL/min. ●Standard flow rate after 15 minutes without reaction is 4mL/min or calculate the order.

CHEST TUBE: “CWS” Collection chamber. ●Water seal bottle/chamber. ●Suction control bottle/chamber.


  • Keep all tubing straight, no kinks or loops. Do not allow patient to lie on it.

  • Use sterile water in water seal and suction control – add as needed.

  • Assess insertion site, v/s and lungs.

  • Never elevate the drainage system above the patient chest.

  • Encourage the patient to do deep breathing to facilitate lung expansion.

  • Keep all connections tight and taped.

  • Monitor fluid drainage and evacuate no > 1000-1200mL. Note: Please check COCA, any clear yellow to bloody drainage report to MD and record it

Common chest tube problems:

  • Air leaks – continuous bubbling in the water seal chamber.

  • Kinks in tubing – no fluctuations in water-seal with inspiration.

  • Insufficient suction – no bubbling in suction control chamber.

  • If drainage system breaks – place the distal end of the chest tubing in sterile water at a 2-cm level as an emergency water seal.

  • If the tube become dislodged – immediately apply a dry sterile dressing (occlusive Vaseline dressing) to the site at the peak of patient’s inspiration. Notify physician immediately. 


-Chest tubes are not clamped routinely: A physician’s order is required. Clamps with rubber protection are kept at the bedside for special procedures such as changing the chest drainage system and assessment before removal of chest tube.

-Clamping of chest tubes during transport or when the tube is accidentally disconnected is no longer advocated.

-Do not milk or strip chest tube routinely because this increases pleural pressure.


Types of administration:

  • Continuous: Feeding is administered continually for 24 hours. Feeding solution infused at regular flow rate. Given to patient with GCS <9/less. An infusion pump regulates the flow. Semi-Fowlers position at all times.

  • Intermittent: Administered by pump 30-90 min. Scheduled similar to meal time. Patient is conscious with GCS >9 and above.

  • Bolus: Administered by gravity or syringe. Higher risk of aspiration, regurgitation and adverse GI effect. A bolus resembles normal meal feeding. Maintain the patient in high fowler’s position for 30 minutes after the feeding.


  • Position:  HOB elevated 30-60 minutes after feeding. Comatose: High fowlers position and on the right side.

  • Assess bowel sounds: Hold feeding and notify physician if absent.

  • Tube patency: intermittent - irrigate with water (30-50mL) before and after each feeding. Continuous – by pump with built in alarm that sound if any BLOCKAGE.

  • Tube position: q before feeding/q 8 hours with continuous feeding.

  • Aspirate stomach content and checking pH (<5 indicate in the stomach). ●CXR: most accurate.

  • Aspirate all stomach contents (residual), measure the amount and return the contents to the stomach to prevent electrolyte imbalance. Usually, if the residual is less than 100 mL, feeding is administered; large volume of aspirates indicates delayed gastric emptying and place the patient at risk of aspiration. Note: if NGT is in the duodenum no need to aspirate for gastric residual.

  • Formula: Given at room or body temperature (decreases risk of diarrhea and GI complications).

  • General nursing consideration: Patient should be weighed daily or several times a week, and accurate I & O monitoring.


Diarrhea: Administer feeding slowly.

Aspiration: Verify tube placement. Do not administer feeding if residual >100 mL. Keep HOB elevated.

Clogged tube: Use liquid form medication. Flush tube 30-50mL water before and after feeding or medication administration.

Vomiting: Administer slowly and at room temp.. Measure abdominal girth. Do not allow feeding bag to empty. Antiemetic.



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